Please fill out and submit the form below, or download the form here to print and complete.

Customer's name*

First Last

Job address*

Street Address Address Line 2 City State ZIP Code

Room*

Selection*

Customer's initials*

Room*

Selection*

Customer's initials*

Room*

Selection*

Customer's initials*

DISCLAIMER: In the event a material selection is changed or altered by the customer, the customer is required to complete a new selections form and will be held responsible for any and all fees associated with returns, restocking, non-returnables, shipping, handling, etc. The customer agrees to fully reimburse Five Star Complete Restoration Inc. within 5 days of a material selection change. Ordering of new selection will not take place until reimbursement is collected in full for any additional fees associated with selection changes.

Customer's signature*

Date*

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